DSM Revision White Paper

NCSF and the NCSF Foundation's position on the discriminatory paraphilias section in the DSM.

Because the scientific evidence contradicts the statements currently within the DSM, we must conclude that the interpretation of the Paraphilias criteria has been politically NOT scientifically based. This politically motivated interpretation subjects BDSM practitioners, fetishists and cross-dressers to bias, discrimination and social sanctions without any scientific basis. We call on the American Psychiatric Association to remove or drastically restructure the Paraphilias section in the DSM.

The American Psychiatric Association's Diagnostic and Statistic Manual (DSM) is the definitive resource on the Diagnostic Criteria for all mental disorders. It influences the International Statistical Classification of Diseases (ICD) and other entities throughout the world.

The DSM-IV-TR definition of a mental disorder is that it is "…a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom… Neither deviant behavior (e.g. political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders…" (p. xxxi)

Yet the Paraphilias section categorizes distress and dysfunction according to certain sexual behaviors, not psychological syndromes or patterns. Behavior itself is not evidence of psychopathology; compulsive hand washing may be a symptom of obsessive-compulsive disorder, but it is not a hand-washing disorder.

A distinction must be made between the cause and the effect. There is no data to support the Paraphilias as the cause of the distress and dysfunction in individuals. In addition, discrimination and societal pressure cause significant distress for a great number of people, in which the societal stigma is the cause rather than the sexual behavior itself.

There are no clear guidelines in the DSM that distinguish a Paraphilia from "healthy" sexuality. Can paraphiliacs be distinguished from those with "healthy" sexuality, except by differences in their sexual behavior? If yes, how? Can someone prefer those exact same behaviors without meeting the diagnostic criteria? Yes, according to the DSM itself (p. 568). So why not just define the abnormal preference instead of the behavior? Diagnostic criteria that pathologize everyone and do not distinguish pathology from normal variants are useless as diagnostic tools.

The Differential Diagnosis of the Paraphilias states:

"A Paraphilia must be distinguished from the non-pathological use of sexual fantasies, behaviors, or objects as a stimulus for sexual excitement in individuals without a Paraphilia. Fantasies, behaviors, or objects are paraphilic only when they lead to clinically significant distress or impairment (e.g., are obligatory, result in sexual dysfunction, require participation of nonconsenting individuals, lead to legal complications, interfere in social relationships). (DSM, p. 568)

Let's examine each of these "indicators" of psychopathology more carefully:

1. Obligatory
Heterosexual behavior is considered "obligatory" by heterosexuals, just as homosexual behaviors are considered "obligatory" by homosexuals. Neither is considered to be a psychopathology like Sexual Sadism, Sexual Masochism and Transvestic Fetishism.

2. Result in sexual dysfunction
43% of women and 31% of men report sexual dysfunction (Laumann, Paik, & Rosen, 1999). Yet the DSM does not contain a diagnosis for people having difficulty with heterosexual interests such as divorce, sexual harassment, not being able to maintain their erotic attraction to their partner, not having enough sex, or not being able to find a relationship. There is no causation data that finds that being heterosexual causes dysfunction, only correlation. There is also no data indicating if sexual dysfunction is more common among heterosexuals than others.

Any sex can be problematic. Masturbation, oral sex and anal sex were once considered to be mental disorders or symptoms of other mental disorders until these behaviors became an accepted form of sexuality. Nymphomania, Satyriasias, and Erotomania are also no longer considered to be mental disorders because these diagnoses impose a cultural value judgment on sexual behavior, rather than comprising a diagnosable entity.

3. Require participation of nonconsenting individuals
Sexual assault is a crime, not a psychiatric diagnosis. Rape is not listed in the DSM. Why do other nonconsensual sex interests have a diagnosis? For Exhibitionism, Frotteurism, and Voyeurism, the diagnosis can only be made if the partner or other person has not consented to the activity. Sadomasochism without consent is a crime; if the behavior is consensual, then it should be considered the same as any other consensual sex act. Pedophilia is a crime because it involves sexual relations between adults and minors.

4. Leads to legal complications
There are a number of legal complications that can arise from consensual sexual behaviors: child custody disputes, divorce settlements, arrest for obscenity and indecency, etc. Historically homosexuals have broken laws and suffered severe social consequences due to their sexual behavior. On this basis some states denied homosexuals the right to adopt because they were breaking the law in their sexual relations. It wasn't until the abolition of state sodomy laws in Lawrence v. Texas (2003) that homosexual activities became legal throughout the U.S. Yet the DSM removed homosexuality as a diagnosis over 30 years ago.

5. Interferes with social relationships
Discrimination and societal pressure over certain sexual behaviors can lead to a great deal of distress and dysfunction. The individual internalizes societal values, creating a conflict between themselves and society. They can encounter prejudice from friends, relatives, partners and co-workers because of their sexual behaviors. This doesn't mean that the individual has a mental disorder. In addition, therapists' beliefs, socialization, and theoretical perspectives will likely affect their judgments of sexual behaviors when they are asked to treat this distress. Thus the Paraphilias are a diagnosis of social/sexual control.

What scientific data supports the diagnoses in the Paraphilias section?

According to the APA, "The utility and credibility [of the DSM]… require that it… be supported by an extensive empirical foundation." (p. xxiii) The DSM-IV-TR's own revision standards are:

"to correct any factual errors…"

"to ensure that all of the information is up-to-date…"

"to reflect new information available…"

"changes had to be supported by empirical data." (p. xxix)

The data in the DSM Paraphilias section is not supported by scientific research:

1. Paraphilias
According to the DSM: "The individual Paraphilias can be distinguished based on difference in the characteristic paraphilic focus. However, if the individual's sexual preferences meet criteria for more than one Paraphilia, all can be diagnosed." (p. 569)

“Unusual” sexual interests are commonly found in the general population (Renaud & Byers, 1999; Sue, 1979)

"There is no empirical research suggesting that even those 'appropriately' (according to the DSM criteria) diagnosed with Sexual Sadism or Sexual Masochism are likely to experience either a dangerous increase in the intensity of their SM interactions nor that Pedophilia is a likely outgrowth of these activities." (Klein & Moser, p. 238)

According to the DSM: "Many individuals with these disorders assert that the behavior causes them no distress and that their only problem is social dysfunction as a result of the reaction of others to their behavior. Others report extreme guilt, shame, and depression at having to engage in an unusual sexual activity that is socially unacceptable or that they regard as immoral." (p. 567)

"Four out of five are satisfied with their S/M orientation." (Levitt et al. p. 472)

According to the DSM: "The behaviors may increase in response to psychosocial stressors, in relation to other mental disorders, or with increased opportunity to engage in the Paraphilia." (p. 568)

"The non-clinical studies of individuals with unusual sexual interests demonstrate that these individuals are indistinguishable from those with 'normophilic' (i.e., conventional) sexual interests." (Moser & Kleinplatz, 2003, p. 96)

2. Sexual Sadism
According to the DSM: "Some individuals with this Paraphilia are bothered by their sadistic fantasies, which may be invoked during sexual activities but not otherwise acted on; in such cases the sadistic fantasies usually involve having complete control over the victim, who is terrified by anticipation of the impending sadistic act. Others act on the sadistic sexual urges with a consenting partner (who may have Sexual Masochism) who willingly suffers pain or humiliation. Still others with Sexual Sadism act on their sadistic sexual urges with nonconsenting victims." (p. 573)

"The data suggest that the majority of rapists are not motivated by sadism." (Groth & Hobson, 1983; Hucker, 1997).

According to the DSM: "Sadistic fantasies or acts may involve activities that indicate the dominance of the person over the victim (e.g., forcing the victim to crawl or keeping the victim in a cage). They may also involve restraint, blindfolding, paddling, spanking, whipping, pinching, beating, burning, electrical shocks, rape, cutting, stabbing, strangulation, torture, mutilation, or killing." (DSM, p. 573)

"The inclusion of nonconsent is especially problematic in the case of Sexual Sadism. Although it is clearly possible for an individual with the diagnosis of Sexual Sadism to engage in nonconsensual acts, most “sadists” do not seek non-consenting partners." (Moser, 1999; Weinberg, Williams, & Moser, 1984)

"Just as it is inappropriate to confuse rapists with those individuals interested in consensual sexual activities, the lumping of individuals interested in consensual sexual sadism with those who engage in non-consensual activities is similarly inappropriate." (McConaghy, 1999)

According to the DSM: "Sadistic or masochist behaviors may lead to injuries ranging in extent from minor to life threatening." (DSM, p. 567)

"Although any sexual activity can lead to injury, there is no data to suggest that the practitioners of “sadistic or masochistic behaviors” frequent emergency departments more often than practitioners of other sexual behaviors. A review of the sports medicine and emergency medicine literature reveals numerous studies of specific injuries related to various sports and other activities. If unusual sexual acts resulted in a significant number of injuries, presumably they, too, would appear prominently in the medical literature." (Moser & Kleinplatz, 2005)

3. Sexual Masochism
According to the DSM: "Except for Sexual Masochism, where the sex ratio is estimated to be 20 males for each female, the other Paraphilias are almost never diagnosed in females, although some cases have been reported." (p. 568)

No studies have been found to support the 20:1 statement. Several studies were found that reported a significant number of women in the SM subculture (Breslow, Evans, & Langley, 1985; Gosselin, Wilson, & Barrett, 1991; Levitt, Moser, & Jamison, 1994). By combining the data of Breslow et al. (1985) and Levitt et al. (1994), a ratio of four male masochists to each female masochist was found. Even if clinical samples are overwhelmingly male, no study supports the naming of a specific ratio.

According to the DSM: "One particularly dangerous form of Sexual Masochism, called "hypoxyphilia," involves sexual arousal by oxygen deprivation obtained by means of chest compression, noose, ligature, plastic bag, mask or chemical (often a volatile nitrite that produces a temporary decrease in brain oxygenation by peripheral vasodilation). (DSM, pp. 572-3)

“In contrast to transvestism, bondage during the fatal asphyxial episode was not differentially associated with any specific erotic object or interest that we examined, even bondage pornography.” (Blanchard and Hucker, 1991, p. 375).

4. Transvestic Fetishism
According to the DSM: "Usually the male with Transvestic Fetishism keeps a collection of female clothes that he intermittently uses to cross-dress. This disorder has been described only in heterosexual males... Although his basic preference is heterosexual, he tends to have few sexual partners and may have engaged in occasional homosexual acts. An associated feature may be the presence of Sexual Masochism." (DSM p. 574)

Summary

Because the scientific evidence contradicts the statements currently within the DSM, we must conclude that the interpretation of the Paraphilias criteria has been politically – not scientifically – based. Because of this, BDSM practitioners, fetishists and cross-dressers are subject to bias, discrimination and social sanctions without any scientific basis. We call on the American Psychiatric Association to remove or drastically restructure the Paraphilias section in the DSM.